Legal Accident Request Form

LEGAL ACCIDENT REQUEST FORM

This Legal Accident Request Form is entered into by Requestor Name: (hereinafter "Requestor") and Legal Representative / Firm Name: (hereinafter "Representative"). The Requestor submits this form to request the Representative to take specified actions and to authorize access to records and communications as set forth below.

RECITALS

WHEREAS, Requestor seeks assistance with matters arising from an accident that occurred on or about at or near (the "Accident"); and

WHEREAS, Requestor desires that Representative request, collect, review and, if authorized below, communicate with insurers and third parties to obtain records, statements and other materials reasonably necessary to evaluate and pursue claims related to the Accident; and

WHEREAS, Representative is willing to act on Requestor's behalf consistent with the scope and limitations set forth in this Form.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained in this Form, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, "Records" means police reports, incident reports, medical records, medical bills, photographs, witness statements, surveillance, vehicle repair estimates, insurance correspondence, and other documentary or electronic material related to the Accident.

2. SCOPE OF REQUEST

Requestor authorizes Representative to undertake the following actions on Requestor's behalf as indicated by checked items and further described below:

3. INCIDENT INFORMATION

4. AUTHORIZATION AND RELEASE

Requestor authorizes and directs any person, business, insurer, medical provider, law enforcement agency, motor vehicle department, employer, or other custodian of records to release Records and to communicate with Representative for the limited purposes described herein. This authorization includes but is not limited to medical information concerning diagnosis, treatment, prognosis, and billing. Representative is authorized to receive, inspect, photocopy, and retain such Records and information as reasonably necessary to evaluate and pursue claims arising from the Accident.

Requestor understands that certain Records may be protected by privacy laws and authorizes their release to Representative to the fullest extent permitted by law. This authorization is limited to actions necessary to obtain Records and to communicate with insurers, adjusters, and other parties involved in investigating or resolving claims relating to the Accident.

5. FEES, COSTS, AND PAYMENT AUTHORIZATION

Requestor agrees to pay or reimburse Representative for reasonable out-of-pocket costs and expenses incurred in obtaining Records, including copying, retrieval, courier, and administrative fees. The Representative may seek prior authorization for any anticipated extraordinary expense.

6. LIMITATIONS; NO ENGAGEMENT UNLESS EXECUTED

This Form authorizes Representative to request and obtain Records and to perform preliminary investigatory actions described herein. It does not, by itself, create an attorney-client relationship or an obligation to provide full legal representation unless and until the parties execute a separate written engagement agreement specifying representation terms. Any legal advice or representation will be subject to the terms of a separate retainer agreement signed by both parties.

7. CONFIDENTIALITY; PRIVILEGE

All documents and communications provided by Requestor to Representative in the course of the actions authorized by this Form will be treated as confidential. To the extent an attorney-client relationship arises, communications and materials will be subject to any applicable privilege. Requestor acknowledges that Records obtained from third parties may not be privileged and may be subject to discovery by other parties.

8. NOTICES

All notices under this Form shall be in writing and delivered to the addresses provided below. Notice is effective upon personal delivery, email with delivery receipt, or three business days after deposit in the United States mail, postage prepaid, addressed to the party's address as set forth below.

9. AMENDMENTS; WAIVER

This Form may be amended only by a written instrument executed by both Requestor and Representative. No failure or delay by either party in exercising any right under this Form will operate as a waiver, unless a written waiver is executed by the waiving party.

10. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the laws of the state in which Representative maintains its principal office as indicated in the Representative Contact Information above, without regard to conflict of law principles. Venue for any dispute arising under this Form shall lie in the state and federal courts located in that jurisdiction.

11. ENTIRE AGREEMENT; SEVERABILITY

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written statements or understandings. If any provision of this Form is determined to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

12. CERTIFICATION

By signing below, Requestor certifies that the information provided in this Form is true and correct to the best of Requestor's knowledge, and Requestor authorizes Representative to take the actions checked and described above. Requestor understands and acknowledges the limitations set forth in Section 6.

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